TMJ and TMD are confusing to most dentists, let alone patients. Headaches, Migraine, Tinnitus, ear pain, vertigo, tingling down the arms are TMJ symptoms that are often misdiagnosed. My purpose is to give solid information to dentists, physicians and patients on TMJ, TMD. I will share its symptoms, diagnostic steps and options for treatment including Neuromuscular Dentistry, Aesthetic dentistry solutions and Neuromuscular Functional Orthodontics.

February 23, 2013

Botox - botulinum toxin type A - has been touted for lots of problems that ail us.

It started off being used for facial cosmetics - to 'relax' wrinkles such as 'crow's feet' on the side of forehead by paralyzing the tiny muscles under the wrinkles. But more and more uses of this drug is promoted all the time.

Recently there is a big push to use Botox injections in the jaw muscles "to treat TMJ". Pharamceutical companies are experts in marketing & have the big money to give grants, sponsor research and sponsor speakers to promote its use. I have seen many patients that had this done repeatedly with less and less effectiveness. They are more difficult to treat - not impossible - since these muscles have been damaged. This is not just my opinion based clinical experience. There are scientific studies that prove this. These jaw muscles are NOT like the tiny facial muscles that cause 'crow's feet' wrinkles on the face that are paralyzed by Botox for cosmetic results. The jaw muscles are important functional muscles! Does paralyzing them with a neurotoxin make a lot of sense to anyone?

Why then do doctors do this to treat TMD & patients go through these injections? Are they just looking for a quick fix? Or are these doctors that push this 'treatment' for TMD just clueless?

What are your thoughts on Botox for TMD treatment? Any of you have personal experience with Botox for TMD? Are you thrilled with the results?

September 30, 2010

Is that a bold thing to say? But it is true. While most dental school professors that "treat" TMJ / TMD don't believe that it is possible, this is not so far fetched for Neuromuscular dentists.

Here is a story of a medical student in her own words. You can hear her passion when she read what AADR - a group of mostly dental school professors are trying to do in setting the standard for all dentists.

Don't get me wrong! I am not painting all dental professors with that broad brush. I loved many of my dedicated teachers in dental school. But I am only referring to this one group - AADR - which is dominated by a group of academics.

Stephanie had jaw pain, neck pain, headache, back pain, fatigue along with worn teeth. Worn teeth were her least important concern. But getting a beautiful smile in the process has to help in her career as a physician and in her life.

Mid-August of 2006, I scheduled my routine dental check-up which resulted with having a cavity filled the next week.After having the cavity repaired, my tooth was hurting more and more.Early Sunday morning I was awakened by the worst pain I had ever experienced.It felt like my head was going to explode, my right eye was droopy, my vision was blurred, and I had an odd sensation on the right side of my head to my arm.I knew I should go to the hospital, but I resisted. My vision continued to vary in my right eye.The following day, my head was better, but still in pain.My tooth pain was also increasing.My doctor was out of town, so I went to a local doctor whom ordered an MRI.Following the MRI, I returned to my dentist because my tooth pain continued to rise.My dentist explained that the actual tooth hurting was not the tooth that had been filled, and if the tooth didn’t quit hurting, I may need to have a root canal.When the MRI results came in, I followed up with my regular physician.He explained that no abnormalities were noted.By this point, the tooth pain had expanded to facial pain…shooting, stabbing, etc.Based on my presentation of symptoms, my family doctor felt that I probably had trigeminal neuralgia and migraines; I was started on Tegretol and prednisone.I experienced minimal improvement while on the medication, so my physician referred me to a neurologist.

October, 2006, my neurologist stated that he felt I had trigeminal nerve pain, but not classic trigeminal neuralgia.I was placed on Neurontin to assist with the facial/eye pain, and later Topamax due to the increase in frequency and intensity of migraines.As time passed, my headaches, eye pain, and facial pain increased.Cold, wind, and touch set my face off in pain.I had increasing pain in and around my right eye.I experienced facial spasms, in which my jaw would draw to the side for hours.Jaw joint pain and facial spasms increased.Due to the presentation of symptoms, my neurologist suspected I had a disorder of the jaw joint and referred me to an oral surgeon in Feb/March of 2007.Due to my training as a speech/language pathologist, I also believed I had a disorder of the jaw joint.I knew my presentation of symptoms was not typical for trigeminal neuralgia or migraines.The oral surgeon disagreed; he stated I was at risk for jaw joint problems due to my closed bite, but at the time I did not have any problems and referred me to an orthodontist to be fitted for a splint to wear at night to help reduce pain.The orthodontist determined that he didn’t know what was contributing to the facial/jaw joint pain, but that a splint would not provide me with the pain relief I was searching for.Upon discussing these findings with my neurologist, he determined that I needed to be referred to a different neurologist; if it wasn’t a jaw joint disorder, he was unsure what it was.He expressed that I was experiencing blepharospasms and possibly a type of facial dystonia, due to the eye and facial spasms, but that would need to be further evaluated.I questioned having my facial muscle and nerves evaluated.I was told that he was unsure of where that could be done, but possibly at the Mayo Clinic.

My neurologist attempted to get me into the Mayo Clinic, but was unsuccessful.So, I was referred to a neurologist in Kansas City.My second neurologist immediately diagnosed me with SUNCT Syndrome (Short-Lasting Neuralgia Form Headaches with Conjunctival Injection and Tearing) and migraines.He was confident that the shooting, stabbing, and electrical pains in my face, eye, head, and temple were due to the SUNCT.He also felt that the eye spasms and drooping were the result of SUNCT.As time passed I was placed on a multitude of medications…neorontin, lyrica, anti-convulsion medications, blood pressure medications, anti-depression medications, etc. with little success.As the months passed, the facial spasms, pain, head, and then neck pain increased.I questioned my neurologist if something else could be occurring.I again asked about the possibility of jaw joint issues.I also questioned having nerve and muscle functioning testing completed on my face.He was adamant that that did not need to be done and that I was experiencing atypical facial pain, migraines, that was it, and to continue his protocol of treatment.He expressed that I needed to understand that some people are disabled by migraines and to continue his trial of medications.I was not going to accept that I was going to be disabled at the age 30.And, by this point (June, 2007), I did feel nearly disabled.I was homebound, with not being able to walk outside or up/down my stairs in my own home.For most of the summer I was too ill to care for my own children, unable to get out of bed for days at a time due to the pain, and equilibrium problems.I would stumble and was unable to walk upright when the pain was flared.I didn’t know how I would be able to start work again after summer break.Searching on the internet, I found a TMJ specialist out of state.I read information on the website, read the doctor’s research, and felt it would be beneficial to be evaluated by him.

Upon evaluation by the TMJ specialist (September, 2007), my jaw was dislocated and locked.The specialist was able to successfully unlock my jaw. I was fitted with a splint to wear around the clock for 2 months and then at night to assist with keeping my jaw from dislocating.It continued to dislocate frequently, but not to the extent it was initially.Later, the specialist diagnosed me with splenius capitis muscle syndrome and temporal tendonitis.I had radiofrequency procedures completed to assist with pain reduction and healing of the nerves.The splenius capitis procedure immediately eliminated the constant pain I was feeling in the parietal area.This was such a relief; I felt like I would somehow now be able to manage.My facial and jaw joint pain, however, continued to increase.An MRI of the jaw joints was later ordered due to the continued increase in pain; however, the results indicated no jaw joint abnormalities.

Throughout this experience I trialed chiropractic treatment, acupuncture, and myofascial release therapies.I do believe that I benefited from the acupuncture.The relief, although, was not long lasting.

Later, I followed up and shared the TMJ information with now my third neurologist (January, 2008).The neurologist agreed that I had SUNCT syndrome.I continued on Topamax and trialed other medications.Again, I experienced limited success with pain reduction/migraine frequency.As time passed, my eye/temple pain and eye spasms increased.My neurologist referred me to a neurologist whom specialized in dystonia.I believe this was one of my most frustrating experiences.He asked me a variety of questions, and everytime I talked about “pain”, he informed me that my regular neurologist would address that.I did not realize as a diagnostician, it was acceptable to pick and choose what symptoms you would listen to.Pain was the major factor in my presentation of symptoms.Well, I was informed my regular neurologist would take care of my pain and headaches and he would address the “other” issues.Given that he was ignoring pertinent information, he proceeded to diagnose me with possibly Tourette’s Syndrome; stating that I didn’t present with the psychological factors common for that identification, or that I presented with an uncommon form of dystonia.He said he would need to see me again to make up his mind…..Desperate for pain relief, I took the clonadin prescribed.I did sleep better than I had for months, but quickly began experiencing bizarre side effects.My face started pulling to the side, and eyes started rolling back.This wouldn’t last long, but it did startle me.I called and discussed this with the prescribing neurologist’s nurse.I was told to increase the medication.By the end of that week, I was admitted to the hospital for six days due to seizures, which consequently stopped after all of the medications were ceased.I again questioned having the facial muscle and nerve functioning assessed.I was told they might do that type of testing at KU, but he didn’t know.He insisted that I needed to accept the diagnosis of migraines and quit searching for a cause.

Once I was feeling better, I felt I needed a follow-up with my TMJ specialist out of state (September, 2008).I traveled to have an evaluation completed which resulted with being told that he was unable to offer any further assistance. He recommended that I follow up with a specialist regarding my neck pain and back pain, and an ENT.So, once home I scheduled an appointment with an orthopedist.I was told by that doctor that everything was structurally acceptable and I may want to see a physical therapist for the pain.I was also seen by an ENT, whom, was unsure of what was contributing to my facial, throat, and ear pain.Soon, my family doctor referred me to a pain clinic due to the severity of my pain, which by that time was impacting my whole body.The pain specialist trialed various injections in my neck, shoulder, and head.The injections in the occipital nerve did help with the pain on the back and side of my head, as well as, the eye pain.

Despite doctors insisting that nothing else could be done other that trialing various medications, I continued to search for assistance and relief. In October of 2008, I discovered Dr. Raman’s website.I read the information and saw that he performs the facial muscle and nerve testing in his office.I was astounded to find out that the testing, that I had requested was actually available nearby.On my way home from a visit at the pain clinic, I stopped in his office to see if I would be a candidate for treatment.An evaluation was scheduled for the next week.Results of the testing indicated significant problems with the jaw joints and that yes, the muscle and nerve functioning was impacted, too.Dr. Raman explained that the MRI is commonly used to assess the jaw joints, but that it is not sensitive to measuring that structure.The CAT scan performed in his office revealed significant damage.At a follow-up appointment I was fitted with a fixed orthotic over my mandibular teeth to hold my jaw in the correct position.I found immediate relief once the orthotic was placed.I experienced a dramatic decrease in migraines and my other neuralgia pain, face, and jaw joint pain began to decrease, also.In addition, I was referred for physical therapy to address my neck and back functioning.

Due to the progress and reduction in jaw joint, facial, throat, ear pain, and headaches during a three-month period, we determined to progress on to the next level of treatment which is orthodontics to permanently adjust my bite to its proper positioning.I have had braces for nearly one year.Although I am not 100% pain-free, I have experienced an 80-90% reduction in the pain I was once experiencing.I know that I can have a bad day or two and that it won’t turn into a bad couple of months or even longer.I have my life back.I no longer wake each day thinking not if it is going to be a good day, but how much pain will today bring….will it be manageable, or debilitating….will I be able to care for my children, or will I have to send them away….I am able to enjoy living, my children, my husband, my family, my friends, my career….I am so thankful for having the ability to live again, to care for my children, and the ability to give my family the mother they deserve.

March 27, 2010

SUNCT headaches are characterized by bursts of moderate to severe burning, stabbing, or throbbing pain, usually on one side of the head and around the eye or temple.

SUNCT stands for Short-lasting, Unilateral, Neuralgiform headache attacks with Conjunctival injection and Tearing. Neurologists believe that SUNCT is one of the Trigeminal Autonomic Cephalgias.

Autonomic nervous system responses include watery eyes, reddish or bloodshot eyes caused by dilation of blood vessels (conjunctival injection), nasal congestion, runny nose, sweaty forehead, swelling of the eyelids, and increased pressure within the eye on the affected side of head.

According to National Institutes of Health, these headaches are generally non-responsive to usual treatment for other short-lasting headaches. Corticosteroids and the anti-epileptic drugs gabapentin, lamotrigine, and carbamazepine may help relieve some symptoms in some patients. Studies have shown that glycerol injections to block the facial nerves that carry pain may provide immediate relief, but the headaches recurred in about 40 percent of patients studied.

We treated a patient that had a SUNCT diagnosis and also had many TMD signs and symptoms. Once the jaw alignment is corrected with NM orthotic, all of her symptoms improved greatly. So when she had an episode of right face and right eye lid drooping, it felt like a recurrence of a nightmare.

Since the SUNCT headache attacks have completely gone for a year since beginning NM treatment, I was confident that we can "cure" this attack with Neuromusucula dental protocols. The mandibular condyle can put pressure on the Facial nerve if the jaw moves towards the back.

IF it were an incurable neurological phenomenon, then nothing I did would matter.

April 14, 2009

How do we KNOW that there is improvement with our therapy? Of course, subjective reports are important. But how do we know that it is simply not the case of a patient desperately hoping for an improvement that overstates the change?

Objective measures confirm or invalidate the subjective findings.

TMJ CT sagittal view Pre-OP With Orthotic...confirming decompression

emg - muscle activity at rest on the left half and at light occlusion- gently touching teeth on right half

April 07, 2009

Once the diagnostic tests revealed where the mandible SHOULD align, the next step is to make that change in a reversible way. Remember! Primum non nocere ("First, do no harm"). IF for some reason the patient does not get better, we need to make her no worse. That means reversibility to the condition when she presented at our office.

Fixed LVI orthotic was placed on the mandible and fine tuned with the K7 instrumentation. The progress is measured 3 ways:

a. Subjective reports

b. Objective tests - K7 scans of emg and mandibular movements and CT scans of the joints and cervical spine

c. Objective / Subjective: Palpations of jaw and neck muscles and TM joints. The pressure of palapation is consistent and objective. But the patient's response is subjective.

The images of the orthotic are below:

This is her report two weeks later. Immediately after delivery Sue had gone on a long planned vacation and just returned for this follow up visit.

March 31, 2009

My challenge was to diagnose very precisely where the jaw fits now (where there are symptoms) and where the jaw SHOULD fit if all the jaw / neck muscles are unstrained AND the jaw joints are in an optimal position as well.

Our Neuromuscular diagnostic protocol includes measuring emg's before and after these muscles are optimized. The end result is the mounted casts aligned with the myobite taken at the end of these tests. We KNOW that the muscles will be unstrained in this position because we measure these muscles when the natural teeth are occluding and when they are occluding on the myobite. When we see that the muscles are much quieter with the myobite, it confirms the correctness of the bite relation.

View from front showing a larger "gap" on her right side, where recent restorations were done.

The anterior posterior discrepancy would explain the many adjustments needed on her upper front teeth after veneers were done....and the pain since the mandible had to posteriorize to avoid this area from proprioception. This explains the joint pain.

In the next post, we would show how this was corrected and the results.

March 24, 2009

Sue suffered with these symptoms (listed below) for over 6 months. She had seen a family physician and a neurologist who had tried various medications, as is the norm. Nothing helped. She finally heeded the advice of a friend who was treated with NM orthotic. So very skeptically, Sue came for an evaluation.

This was her baseline form. We choose to use a "comfort scale" instead of the usual "Pain scale". So a Zero is the worst. Her pain when chewing and pain the TM joints were Zero - meaning constant, severe pain. All her other symptoms were in the "Severe" range, as can be seen above.

September 28, 2008

It is common for the chronic TMD sufferers to have over stretched the ligaments of the TMJ. This results in the joints being too loose. When sleeping, the jaw often falls back and interfers with breathing. There are studies that link bruxism ( clenching and grinding) to Sleep Disordered Breathing.

Gilles Lavigne, a researcher in the Faculties of Dentistry and Medicine at Université de Montréal, explains that “the development of neurobiology has enabled us to better understand the structure of sleep in clenchers and to define bruxism clearly as one of many cyclic phenomena that are characteristic of sleep.” The researcher and his team at Sacré-Cœur hospital in Montréal have now gained international recognition for establishing criteria to identify nocturnal bruxism.

Many medications that are classified as Selective Serotonin Reuptake Inhibitors (SSRI) have been shown to induce clenching especially during sleep.

Drugs in this class include (trade names in parentheses): (source: Wikipedia)

These medicines are used so commonly for a long list of indications, this is definitely something to be aware of.

When I wear my seat belt before driving my car on the street, it does not show a lack of confidence in my driving ability. There are other drivers on the road that may be impaired or inattentive. There may be a mechanical problem such as a blown tire from a nail on the street. So wearing a seat belt is a sensible thing to do.

If we prescribe a sleep appliance such as Somnomed MAS after finishing a Neuromuscular Reconstruction, it shows prudence. Not a lack of belief in our ability. Just like wearing a seat belt.

With this level of attention to muscles, posture and joints as well as micro occlusion of the bite, most of the usual reasons for breakage of restorations (crowns, veneers etc.) are successfully addressed. As such the usual cause of breakage, interferences when chewing and bruxism is resolved to a great extent.

Should a NM dentist then prescribe a "seat belt" for his restored patients? If he or she gives a sleep appliance or night guard, after NM full mouth resotrative treatment, does it exhibit a lack of confidence in the priciples of Neuromuscular dentistry?